Provider Demographics
NPI:1194703363
Name:KIBRIA, ESHAN MALIK (DO)
Entity type:Individual
Prefix:
First Name:ESHAN
Middle Name:MALIK
Last Name:KIBRIA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5475 GOLDEN GATE PKWY STE 4
Mailing Address - Street 2:STE 2
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34116-7529
Mailing Address - Country:US
Mailing Address - Phone:239-353-1555
Mailing Address - Fax:239-353-7001
Practice Address - Street 1:5475 GOLDEN GATE PKWY STE 4
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34116-7529
Practice Address - Country:US
Practice Address - Phone:239-353-1555
Practice Address - Fax:239-353-7001
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-06
Last Update Date:2016-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0S 60262084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
C68721Medicare UPIN
FL82883Medicare ID - Type Unspecified